Payment Integrity Analyst

Independently investigate moderate-to-complex data mining leads, claim inventories, and audit findings for errors, including DRG validation and billing inaccuracies Determine error sources and recommend remediation actions Develop logic for data mining concepts based on overpayment identifications Utilize AI, predictive analytics, and SQL to identify patterns of improper spend, false positives, and trends Apply CPT, ICD-10, HCPCS, and NDC coding systems alongside provider contract terms to ensure accurate reimbursement Research and interpret CMS, DHCS, and industry billing guidelines Create detailed, audit-ready case notes and maintain documentation for disputes, appeals, and client inquiries Identify root causes of claim errors and suggest improvements to business rules and operational workflows Update business rules, system edits, configuration, and pre/post-pay controls to reduce recurring improper payment trends Collaborate with clinical, legal, IT, SIU/FWA, provider relations, Medical Economics, providers, and clients Deploy logic and run it against claims-paid data to produce overpayment reports Ensure claim activities comply with CMS regulations and internal policies Escalate potential fraud, waste, or abuse concerns to SIU/FWA teams Assist with provider inquiries, disputes, case summaries, claim validation, and appeals Create audit results information for the CART team for lettering and recovery Perform other duties required to support Health Plan operations and department business needs Support IEHP Quality Program goals, including

HEDIS

, CAHPS, and NCQA Accreditation Requirements A minimum of three (3) years of experience in a combination of healthcare claims processing, billing, and/or auditing functions required Experience with contract and Division of Financial Responsibility (DOFR) interpretation Experience with data analysis/queries Bachelor’s degree in healthcare, finance, or a related field from an accredited institution required In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required Certification in RHIA, RHIT, CCS, CPC, CIC or similar certification preferred Strong understanding of medical coding (CPT, ICD-10, HCPCS) and health insurance contracts Strong understanding of the full claims lifecycle, including share of cost and coordination of benefits Strong understanding of Medicaid/Medi-Cal or Medicare regulatory frameworks Strong understanding of payment integrity concepts, including pre-pay audit, post-pay audit types, DRG validation, and coordination of benefits Intermediate SQL and Microsoft Office Suite (Excel, Access) required Demonstrated ability to make independent decisions in claim coding and adjudication Strong analytical, problem-solving, and trend analysis skills Ability to translate analytical findings into operational recommendations Solid organizational and planning capabilities Ability to communicate effectively with internal stakeholders and external parties Ability to independently prioritize caseloads based on impact and timelines Core Competencies Demonstrates expertise in healthcare claims processing, billing, and auditing, with a strong focus on data analysis and compliance with regulatory frameworks. Proficient in medical coding systems and capable of translating analytical findings into actionable operational improvements. Highest-signal resume keywords Healthcare Claims Processing Data Analysis/Queries Medical Coding (CPT, ICD-10, HCPCS) Intermediate SQL Payment Integrity Concepts ATS Optimization Keywords Hard Skills Data Mining DRG Validation Billing Inaccuracies Predictive Analytics Overpayment Identification Audit Documentation Root Cause Analysis Business Rules Update Claims Lifecycle Understanding Contract Interpretation Soft Skills Analytical Skills Problem-Solving Organizational Skills Effective Communication Independent Decision-Making Certifications & Qualifications RHIA RHIT CCS CPC CIC Industry Keywords CMS Regulations Medicaid/Medi-Cal Medicare HEDIS

CAHPS

NCQA Accreditation Fraud, Waste, and Abuse Provider Relations Audit-Ready Case Notes Operational Workflows Tools & Technologies Microsoft Office Suite SQL #J-18808-Ljbffr Jobtailor